Provider Demographics
NPI:1063653509
Name:SENIOR, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:SENIOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5763 LUNA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-4245
Mailing Address - Country:US
Mailing Address - Phone:706-568-1147
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-596-5583
Practice Address - Fax:706-596-5589
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker